HomeMy WebLinkAbout1253A 0373A • ` i
1�H�ORKERS'COM7ENSATICN OfCIARATION '
I�tiere6y oif�rm thot I have o cer�if�co�e of�o�,e�,.o,��{ APPLICATION FOR BUILDING PERMIT ' �
ir.sure,o�a cert�fico�e of 1V0lAPl3 Compensa�ion Insuranc^,
cr a carrified topY ihcreal(Sr,c.??00.Lab.C.� / � �
���I I G �f�A'(C7"NiJD COUNTY OF LOS ANGELES BUILDING AND SAFETY
V❑olicy No � �J Company BUIlCi4G
Cer'il�ed copy is hereby f�rniihed. FOR APPLICANT TO FILL IN �
� PY� Y '+F�' BU'lD'NG � , ADC4_5S ZZ� � � - . L
Certified ce s iiled with the counl buildin /
IiO�dPPO��mC��. ADD4E5$ 2G��� �. � -
Da1e J�('J�'��APPlicanr- / .../ �� CITY 1/� .� �IZIP � LOCAIITV '...\ \ �^ . C `j�
CERTIFICAIE OF EXE.M.PTION FROM WORKERS' NO.OF gtDGS. NEA4E5T
COMPENSATION INSURAhCE SIZE CF l0T NOW 04 lOT CRCSS ST.
(This Srt�io���ed nel br.completed i1 the permi�Is for onn TRACT ��J�� bIOCK �f0( LOT NO. ASSESSCQ
hundred dallors�5100)or less.) IJA�BOOK PAGE PARCEL
CWf�ER �/ (yC �O 1�F� USE ZCtiE �•'�?
I certify Ihat In the performante o(the work for whlch lhis h�� ��
permil is issue!d,I shall not employ ony person in ony monner ,� S:ECIAL �
so as to become subjnct to rhe Workeri Compensarian Lows. AD7RF55 COhDITIOhS �
U
Date Applicanl C�Tr Z�P �
NOTICE TO APPLICANT: I(, c�ter moking ihis Cerliiico!e of ARCHITECTOR TEI. DiSTRiCT GaCu� ivFE F.rti :'�OCESSED9Y O
Exemp��on, you should become subleer 10 1hc Workeri fNGi�FEx NO. F (� CONS�T. ZON: F'
Compensaiion p�ovis�ons o1 tha labor Code,you musl for�h- qD��E55 \O `\� v V W
wi�h comply w'�h e�ch provis�ons or this permi� sholl be '�� n.�
deemed ravokpd. � TE�� STATISiICAL C1A55,FICATION APT. CON'�O. N
covTanaoa � S1D Eot .lA1CNo. t� , z
IICENSED CONTRAGTORS DECLARATION p� �7 �i�, -7^ CtAS$N0.�OWELL.UNITS
I hereby offirm that I am I�censed under provisions of Chopier 9 nDOR[55 ,VO � [i NO.���f'TZ
(comme�ting wnh S!!cYon 7000)of D�vision 9 ef ihe Business and � /" ��� Si�SER 1MP
Professians Code,ond my license is in full iarce ond ef(r.cl. CITV i� �./ C.tk GLp55 C- 3 �K � VALIDATION
/� �� SO.fT.6• / NO.CF NO.CF CHECK
License Number 7+7 �� Lic.Glass,� -� SiZE 1Z7 STCR�ES va!r:liES ONE
7 [� O VqIUATION
Controc�o�1`.'�-'f1n�-�Doie �. f.•U7 DESCRiPi!040FwCQK h�w : �y "1 2^J�
p o��e+�t� � ,� o A�R o � co C� , ;� . . .� t
i I am ezempt under Set. � o
B.BP.C.Icr th�s rcoeon �d �� s eiL ei2`+'L— pE,�ig � f -� { . •J�G l�
USE CF � I
Dale: ExiSTivGBIDG.�����- •� C�.�OL �
AF�I�ANT !EL. • � •J!`.r U�
$ignaturn ' FINAL
(PPIM)
OWhER-BUItDc2 DECLARqT10N �� ` N`�.7 - � DATE . � �::.�� �3'�
I hereby off�rm ihal l am eaemp�from tha Comroc�or's License q�^��SS �,�,/
law Ior�ha iollowing reason�Sec�ion 7071.5,Business and i FINAI ��F��
Prcle•sio^s Ced�)� , .,� ; 6y 'v i�
❑ 9U'lC!NG i � .
I,os owner of i!^e prooerfy, or my employres wilh ACpF[$S '
wagns os ihei�sole comp�nsatian,will do ihe wcrk and ' �' C��
�ho s�ruclure i�no��niended cr offe�?d for sata(Sectien lOCntiiv ��.}�� '^ -;/ �=��j']?���
70aa,Bus�ness and Professions Ccde). M1��OViNG TFI. � Gr7
� 1,as ownr.r of tho propr.r�y,om r.clusively canlracting CONTRACTOQ NO. �,�4U`,i '; • • •7 j
wi'h licensed t�n!rec!ors to cons!ruct the projecl(S�t- � � � l
lion 704e,Busine�s and Professions Code). A�D4E55 � . a 4 G L II
F[(;UI:CD i0iA15�7?A[lr v. [+.i i
CONSTRUCTION IENDING AGENCY SE�enCK YARD Mwv �aC�.L�:� w'�fH • . "
I hereby allirm thot thcrc is a tons�r�ction lendin�ogency ior �uCv� �������3"
tho pe.Iormance af�he work for which this permit is issued a t. �•�,�O_&l 7
(Set.3097,Civ.C.). SiDE
P.l.
Lender's Aame Q
P.0 Fee S , Permi�Fen S7 J�0 �DVA Rnf.N
9 Lender's Address '
� 1 ccrtify Ihal I have read Ihis aFPlitalion and stofe ihat Iho I»uo�ce Fe� GS-..�� IDMA P/C M
� above iniormotian is carrect I ag�ee�o comply with all Covnty imesu�o��on fee .t�
8 ord�nonces and Slale laws reloting to buildint�canslru:llon, To�ol Fee • v�+ LDMA Perm.M
and hereby aulhorire represen�olivee oi Ihis County Io nmer
� opon�he abovx� � / . ..rFTy stx inspecl on purposes,
�-'�(��� SFE REVFRSF FOR E%►LANATORY IANGVAGE
��of A�pl�con��� gen - pare
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